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ENGLISH NATIONAL ROOT-CAUSE ANALYSIS OF POST-COLONOSCOPY COLORECTAL CANCERS

Nicholas E Burr 1, David Beaton 2, Nigel Trudgill 3, Eva Morris 4, Roland Valori 5

Affiliations

1 Mid-Yorkshire Hospitals NHS Trust, Wakefield, United Kingdom

2 The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, United Kingdom

3 Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, United Kingdom

4 University of Oxford, Oxford, United Kingdom

5 Gloucestershire NHS Foundation Trust, Cheltenham, United Kingdom

Summary

AI Generated

A national English NHS audit of 1724 post-colonoscopy colorectal cancers found that 70% were potentially avoidable and 16% caused major harm or premature death due to delayed diagnosis.

Of 1724 audited post-colonoscopy colorectal cancers occurring 6-48 months after index colonoscopy, 70% were judged potentially avoidable (4% definitely, 13% probably, 53% possibly)
17% of cases were diagnosed in a different hospital from where the index colonoscopy was performed, representing cases that would not normally be known to the original site
Photographic evidence of colonoscopy completion and rectal retroflexion was absent or inadequate in over 50% of cases where it was deemed important
WEO category distribution was 68% adequate examination, 18% inadequate examination, 9% no lesion resected, and 5% likely incomplete resection
Patient, clinical, and administrative factors contributed to post-colonoscopy cancers in 10%, 10%, and 5% of cases respectively

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This summary was generated by an AI large language model based on the content transcript. It is for informational purposes only and should not be considered a substitute for clinical judgment. Always rely on your professional expertise and the full clinical context when making clinical decisions.

Abstract

Introduction

Post-colonoscopy colorectal cancers (PCCRCs) represent missed opportunities to diagnose or prevent colorectal cancer. Up to 89% of PCCRCs are avoidable [1], but identifying PCCRCs for root-cause analysis can be difficult, especially when the cancer is diagnosed in a different hospital from the index colonoscopy.

Aims & Methods

The aim of this study was to create a process for identifying PCCRCs for all English National Health Service (NHS) hospitals, introduce a case review template to identify the most plausible explanation for PCCRC, and use the evidence captured to inform recommendations for reducing PCCRC rates.
PCCRCs occurring 6-48 months after an index colonoscopy (PCCRC-4yr) were identified by linking datasets (cancer registry and hospital episode statistics) and uploaded into a secure portal with an audit template based on World Endoscopy Organisation (WEO) recommendations and a previously published case review [1]. WEO categories were applied to determine a plausible aetiology based on whether adenomas were detected in the same segment (adequate examination (A), inadequate examination (B)), and if a lesion was resected (no (C), yes, and likely incomplete resection (D)). PCCRC were also stratified based on whether they occurred before (interval), at (non-interval A), after a planned surveillance procedure (non-interval B), or where no surveillance was planned (non-interval C). This method was tested at 10 pilot sites, refined, and then rolled out nationally. A maximum of 25 PCCRCs were uploaded to 126 hospital sites.

Results

2,465 PCCRCs were uploaded to the portal. 122/126 sites participated. In total, 459 patients were excluded from the study after the initial review. A complete audit dataset was available for 1724 of the 2006 remaining PCCRCs (86% compliance). In 294 of the 1724 (17%) audited PCCRCs, index colonoscopy was performed in a different organisation from where the cancer was diagnosed. Overall, 1190 (70%) were potentially avoidable (4% definitely, 13% probably, and 53% possibly). 16% of PCCRCs were judged to have caused major harm or premature death due to a delay in diagnosis. Photographic evidence of completion and rectal retroflexion was absent or inadequate in >50% of cases, where it was deemed important. There were 1179 WEO A (68%), 308 WEO B (18%), 157 WEO C (9%), and 80 WEO B (5%). There were 315 interval PCCRC (18%), 280 non-interval A PCCRCs (16%), 179 non-interval B PCCRCs (10%), 773 non-interval C PCCRCs (45%), and 177 unknown PCCRCs (10%). Patient, clinical, and administrative factors were involved in 10 %, 10%, and 5% of cases, respectively.

Conclusion

A process for identifying PCCRCs in the English NHS has shown that 17% of cases are diagnosed in other hospitals, cases that would not normally be known to the site of the index colonoscopy. This initial analysis of completed audits of 1724 PCCRCs provides the largest dataset of aggregated data on PCCRCs and the only one for an entire country. This confirms that the majority of PCCRCs are not just avoidable, but the delay leads to moderate-to-severe harm and even premature death in a large proportion of patients. Unlike multivariate analyses of large datasets, it provides detailed information on what leads to delays in diagnosis and what needs to be done to reduce the number of PCCRCs. Large dataset analyses are important to highlight potential variations in colonoscopy performance, but detailed case reviews are needed to determine the aetiology of PCCRC, provide a mechanism to provide feedback to colonoscopists and patients, and formulate improvement plans.

References

Anderson, R, Burr, N, Valori, R. Gastroenterology 2020;158:1287-1299

Conference

UEG Week Copenhagen 2023

Topics

Colorectal

Submission format

Abstract

Session

Endoscopy and beyond (Posters)

Citation

United European Gastroenterology Journal 2023; 11 (Supplement 8)

Published

2023

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